The
rejiggering of how doctors, hospitals, governments, and insurance
companies do business togetheras though they comprised a widget industryputs
the emphasis on procedures and systems instead of people, Kagan argues.
American health-care is very much about fitting into the boxes. I
worry about the fact that we create structures where were checking
boxes rather than figuring out what individual patients need.

In her clinical practice, Kagan is very much about listening to how
patients and families talk about themselves, their lives, and their
ills. I think the typical thingand this is what we teach cliniciansis
to have a basic framework of, If this, then that. We try to use logical
paths for decision-making. I think that its harder to teach the relationship
piece, though we emphasize it quite a bit in medical and nursing education.

Because they are experts, Kagan points out, health professionals often
feel pressure to provide answers, to tell patients what they
need to do rather than listen to them talk about what hurts, where
the itch is, how tired they are, what theyve done about it, and how
illness has changed the way they live. It is precisely in these narratives,
she has discovered, that much of the needed diagnostic and treatment
information can be found. She acknowledges the time burdens that doctors
and nurses labor underthe need for efficiency imposed by managed
care. But putting in the time upfront, she insists, to hear symptom
stories or to probe for what patients are experiencingand what they
hope foris not more time-consuming but less.

As
nurses, its our responsibility to step back and say, Lets find
out where this person is now and what responses to illness are evident,
and not make judgments about how much assistance this person needs.
My job is to fix what I cannot to cure diseases but to fix symptoms
and side effectsand then help people sort out for themselves how
theyre going to live with whatever remains. My job is to ask, Whats
bothersome, and what do you want to do about it?

Much of Kagans research and clinical practice relates to care of
the elderly, particularly old people with cancer. Since cancer is
the third leading cause of death in adults over 65, notes Strumpf,
the nurse-scholars approach to health-care will become increasingly
important as society grows older.

Currently, more than 12 percent of the U.S. population is age 65 or
over, which comes to about 35 million people. Over the next three
decades, the number of older Americans is expected to double. They
will make up nearly 20 percent of the census count by 2030.

In 1900, the average life expectancy was just over 47. By 2050, it
is projected that the average American will live a little more than
80 years. There is, I think, a very fervent American hope or belief
that health will come without a price and that cure comes at no cost,
Kagan muses. Ours is not an infinite lifespan. I dont think well
be able to cure the fundamental problem of senescencethe fact that
the minute our organism is fully formed there are aging processes
that immediately kick inand with senescence comes increased risk
of disease.

As the population grows older, society will assume an ever greater
burden of disease and disabilitythe cost of longevityincluding a
higher incidence of cancer. Cancer rates increase sharply with age.
More than half of all malignancies and more than 70 percent of cancer
deaths occur in the elderly. What we know about cancer is that youre
much more likely to be old and have cancer than to be young. So the
common experienceand one that most American adults these days have
at least cursory familiarity withis that youre old, youre frail,
you have cancer, you have other chronic diseases.

There are now more than 4 million people age 85 and over. This most
frail age group is the fastest growing segment of the population and
is expected to hit 19 million half-way through the 21st century.

Its
a really scary curve, says Kagan. Those people will have differential
disease patterns for which our systems of care are not well equipped,
and were still allocating way too few dollars and way too little
public policy and thought to figuring out how were going to create
a seamless system of care that doesnt make people who will be providing
for their older relatives wish that they could die.